=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750498044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARKETIME DRUG OF MOSCOW INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 872 TROY RD STE 120
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-7541
-----------------------------------------------------
Fax | 208-883-4716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 872 TROY RD STE 120
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-7541
-----------------------------------------------------
Fax | 208-883-4716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ERIK JAMES NELSON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 509-455-9345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 217CP
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------